Chest X-ray Interpretation

Bucky Boaz, ARNP-C


Routinely obtained  Pulmonary specialist consultation  Inherent physical exam limitations  Chest x-ray limitations  Physical exam and chest x-ray provide compliment

Essentials Before Getting Started

– Overexposure – Underexposure

Sex of Patient
– Male – Female

Essentials Before Getting Started  Path of x-ray beam – PA – AP  Patient Position – Upright – Supine .

Essentials Before Getting Started  Breath – Inspiration – Expiration .

Systematic Approach  Bony Framework  Soft Tissues  Lung Fields and Hila  Diaphragm and Pleural Spaces  Mediastinum and Heart  Abdomen and Neck .

Systematic Approach  Bony Fragments – Ribs – Sternum – Spine – Shoulder girdle – Clavicles .

Systematic Approach  Soft Tissues – Breast shadows – Supraclavicular areas – Axillae – Tissues along side of breasts .

Systematic Approach  Lung Fields and Hila – Hilum   Pulmonary arteries Pulmonary veins Linear and fine nodular shadows of pulmonary vessels – Lungs  – Blood vessels – 40% obscured by other tissue .

Systematic Approach  Diaphragm and Pleural Surfaces – Diaphragm   Dome-shaped Costophrenic angles – Normal pleural is not visible – Interlobar fissures .

Systematic Approach  Mediastinum and Heart – Heart size on PA – Right side     Inferior vena cava Right atrium Ascending aorta Superior vena cava .

Systematic Approach  Mediastinum and Heart – Left side      Left ventricle Left atrium Pulmonary artery Aortic arch Subclavian artery and vein .

Systematic Approach  Abdomen and Neck – Abdomen   Gastric bubble Air under diaphragm Soft tissue mass Air bronchogram – Neck   .

Summary of Density  Air  Water  Bone  Tissue Tissue .

Pitfalls to Chest X-ray Interpretation

Poor inspiration  Over or under penetration  Rotation  Forgetting the path of the x-ray beam

Lung Anatomy

Trachea  Carina  Right and Left Pulmonary Bronchi  Secondary Bronchi  Tertiary Bronchi  Bronchioles  Alveolar Duct  Alveoli

Lung Anatomy

Right Lung
– Superior lobe – Middle lobe

– Inferior lobe

Left Lung
– Superior lobe – Inferior lobe

Lung Anatomy on Chest X-ray  PA View: – Extensive overlap – Lower lobes extend high  Lateral View: – Extent of lower lobes .

the RUL is adjacent to the first three to five ribs. the RUL extends inferiorly as far as the 4th right anterior rib .Lung Anatomy on Chest X-ray    The right upper lobe (RUL) occupies the upper 1/3 of the right lung. Anteriorly. Posteriorly.

and appears triangular in shape. being narrowest near the hilum .Lung Anatomy on Chest X-ray  The right middle lobe is typically the smallest of the three.

separated from the others by the major fissure. Review of the lateral plain film surprisingly shows the superior extent of the RLL.Lung Anatomy on Chest X-ray    The right lower lobe is the largest of all three lobes. and extends inferiorly to the diaphragm. . the RLL extend as far superiorly as the 6th thoracic vertebral body. Posteriorly.

The minor fissure separates the RUL from the RML. Oriented obliquely. the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body. .Lung Anatomy on Chest X-ray    These lobes can be separated from one another by two fissures. and thus represents the visceral pleural surfaces of both of these lobes.

there are only two lobes on the left.Lung Anatomy on Chest X-ray  The lobar architecture of the left lung is slightly different than the right.  Because there is no defined left minor fissure. the left upper .

Lung Anatomy on Chest X-ray  Left lower lobes .

The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe. identical to that seen on the right side. . although often slightly more inferior in location.Lung Anatomy on Chest X-ray   These two lobes are separated by a major fissure.

4. 5. 8.The Normal Chest X-ray  PA View: 1. 6. Aortic arch Pulmonary trunk Left atrial appendage Left ventricle Right ventricle Superior vena cava Right hemidiaphragm Left hemidiaphragm Horizontal fissure . 2. 9. 3. 7.

Retrosternal space . Thoracic spine and retrocardiac space 4. Oblique fissure 2.The Normal Chest X-ray  Lateral View: 1. Horizontal fissure 3.

An intrathoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border. will obscure that border.The Silhouette Sign  An intra-thoracic radioopacity. . if in anatomic contact with a border of heart or aorta.

Putting It All Together .


Understanding Pathological Changes  Most disease states replace air with a pathological process  Each tissue reacts to injury in a predictable fashion  Lung injury or pathological states can be either a generalized or localized process .

Liquid Density Liquid density Increased air density Generalized Localized Infiltrate Diffuse alveolar Consolidation Diffuse interstitial Cavitation Mixed Mass Vascular Congestion Atelectasis Localized airway obstruction Diffuse airway obstruction Emphysema Bulla .

and No significant loss of lung volume .Consolidation  Lobar consolidation: – Alveolar space filled with inflammatory exudate – Interstitium and architecture remain intact – The airway is patent – Radiologically:    A density corresponding to a segment or lobe Airbronchogram.

Atelectasis  Loss of air  Obstructive atelectasis: – No ventilation to the lobe beyond obstruction – Radiologically:    Density corresponding to a segment or lobe Significant loss of volume Compensatory hyperinflation of normal lungs .

2. 4. 5.Stages of Evaluating an Abnormality 1. 3. Identification of abnormal shadows Localization of lesion Identification of pathological process Identification of etiology Confirmation of clinical suspension  Complex problems    Introduction of contrast medium CT chest MRI scan .

Putting It Into Practice .

Case 1 .


One-third of SCC masses show cavitation . 3cm relatively thin-walled cavity is noted in the left midlung.A single. This finding is most typical of squamous cell carcinoma (SCC).

Case 2 .


Notice over inflation on unaffected lung .LUL Atelectasis: Loss of heart borders/silhouetting.

Case 3 .


Right Middle and Left Upper Lobe Pneumonia .

Case 4 .


Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. . Notice air fluid level.

Cavitation .

Case 5 .


Tuberculosis .

Case 6 .


and increase in the size of the retrosternal air space. flattening of the diaphragm. In addition the upper lobes will become hyperlucent due to destruction of the lung tissue. .COPD: increase in heart diameter.

Chronic emphysema effect on the lungs .

Case 7 .


Recall that fluid and soft tissue are indistinguishable on plain film. reveals a classic pleural effusion in the right pleura. Further analysis. however.Pseudotumor: fluid has filled the minor fissure creating a density that resembles a tumor (arrow). Note the right lateral gutter is blunted and the right diaphram is obscurred. .

Case 8 .


Knowledge of lobar and segmental anatomy is important in identifying the location of the infection .Pneumonia:a large pneumonia consolidation in the right lower lobe.

Case 9 .


Curly lines. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema. . and an enlarged heart.CHF:a great deal of accentuated interstitial markings.

24 hours after diuretic therapy .

Case 10 .


Chest wall lesion: arising off the chest wall and not the lung .

Case 11 .


Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis .

Case 12 .


Lung Mass .

Case 13 .


Small Pneumothorax: LUL .

Case 15 .


Right Middle Lobe Pneumothorax: complete lobar collapse .

Post chest tube insertion and re-expansion .

Case 16 .


Metastatic Lung Cancer: multiple nodules seen

Case 17

Right upper lower lobe pulmonary nodule .

Case 18 .


Tuberculosis .

Case 19 .


Perihilar mass: Hodgkin’s disease .

Case 20 .


Widened Mediastinum: Aortic Dissection .

Case 21 .


Pulmonary artery stenosis with cardiomegally likely secondary to stenosis. .

Questions? .

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